In: Health19 Nov 2009
Ketamine has been used as an oral sedative in the management of uncooperative patients. Common side effects of ketamine are nausea and vomiting, which have been reported in 0-43% of patients. In this study, the addition of promethazine, a potent antiemetic drug, reduced the vomiting incidence from 27% (control group) to 0% (experimental group).
Patients given oral ketamine achieved sedation in approximately 25 minutes as evidenced by their drowsiness when separated from the parents and the presence of a blank stare. The blank stare and nystagmus are typical effects seen with ketamine administration. It should be noted that some of the parents who were unfamiliar with ketamine sedation were not totally comfortable seeing their child sedated and demonstrating a blank stare and nystagmus. Explaining to the parents the expected clinical side effects of ketamine, especially about the nystagmus, is helpful in making them more at ease and relieving unnecessary anxieties.
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One patient from the control group (3Vi years old) said that she had a nightmare after the dental treatment was completed. The parent also reported later that the patient complained of nightmares while she was in the waiting room after she was given the ketamine. After the appointment, the parent did mention that the child had a history of nightmares and that she would sometimes wake up at night crying.
The follow-up telephone calls revealed that most patients slept after returning home. The postoperative drowsiness and sleep for both groups ranged from 15 minutes to 6 hours, with an average of 3 hours. However, these data were obtained subjectively from the parents by their recall and were not precisely measured. The sleep pattern as reported by the parents appeared to be intermittent, with periods of wakefulness in between. There were no other adverse problems except for the incidences of vomiting previously discussed.
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The results of the general behavior rating between the 2 groups were not as expected. There was a trend for promethazine to decrease in incidence the vomiting, but it did not improve the sedation in the study group as might be assumed. At this time, the presumed pharmacological interaction between ketamine and promethazine is not known. It is questionable whether pro methazine may reduce the sedative effect of ketamine. The small patient sample in this preliminary study may have influenced the statistical outcome of the study as well. It may be speculated that a larger patient sample could possibly yield different results. It has been suggested that the addition of a different antiemetic agent to ketamine may produce a different result from that obtained from this study. Since hydroxyzine is also used in pediatric dentistry as a mild sedative and as an antiemetic drug, its combination with ketamine has potential merits and a future clinical evaluation is warranted.
From this study, ketamine provided good to excellent sedations in most patients. Promethazine appeared to decrease the vomiting when added to ketamine. The combination of ketamine and promethazine yielded adequate sedations but was not as effective as ketamine alone.
Blog invites submissions of review articles, reports on clinical techniques, case reports, conference summaries, and articles of opinion pertinent to the control of pain and anxiety in dentistry.